A client reports confusion and blurred vision after receiving a dose of glipizide. Which action should the nurse implement?

Perform a neurological exam.

Obtain a fingerstick blood glucose.

Administer glucagon intramuscularly.

Measure the client's vital signs.

Answer and Explanation

The Correct Answer is B

Choice A reason: Performing a neurological exam is not the priority action in this situation. Confusion and blurred vision are signs of hypoglycemia, which is a low blood sugar level. Glipizide is a medication that lowers blood sugar by stimulating the pancreas to produce more insulin. The nurse should first confirm the blood sugar level before performing any other assessments or interventions.

Choice B reason: Obtaining a fingerstick blood glucose is the best action in this situation. This is a quick and easy way to measure the blood sugar level and determine if the client is experiencing hypoglycemia. The nurse should use a glucometer and a lancet to prick the client's finger and obtain a drop of blood. The nurse should compare the result with the normal range and follow the hypoglycemia protocol.

Choice C reason: Administering glucagon intramuscularly is not the first action in this situation. Glucagon is a hormone that raises blood sugar by stimulating the breakdown of glycogen in the liver. It is used as an emergency treatment for severe hypoglycemia, when the client is unconscious or unable to swallow. The nurse should only administer glucagon after confirming the blood sugar level and trying oral glucose first.

Choice D reason: Measuring the client's vital signs is not the priority action in this situation. Vital signs include blood pressure, pulse, respiration, and temperature. They can provide information about the client's overall health and stability, but they are not specific to hypoglycemia. The nurse should focus on the blood sugar level, which is the most relevant indicator of hypoglycemia.

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Correct Answer is D

Explanation

Choice A reason: This is not an appropriate action for the nurse to take. Increasing the intake of saturated fats will worsen the side effects of orlistat, which inhibits the absorption of fats in the intestine. The client should be advised to follow a low-fat diet while taking orlistat.

Choice B reason: This is not an appropriate action for the nurse to take. Oily stools and flatus are common and expected side effects of orlistat, and they do not indicate a serious adverse reaction. The client does not need to stop taking the drug or contact her healthcare provider unless the symptoms are severe or persistent.

Choice C reason: This is not an appropriate action for the nurse to take. Obtaining a stool specimen to evaluate for occult blood and fat content is not necessary for a client taking orlistat. The presence of fat in the stool is normal and expected with orlistat, and there is no evidence of bleeding in the client's case.

Choice D reason: This is the appropriate action for the nurse to take. Asking the client to describe her dietary intake history for the last several days will help the nurse assess the client's compliance with the recommended low-fat diet and provide education and counseling as needed. The nurse can also monitor the client's weight loss progress and adjust the dosage of orlistat accordingly.

A. Eliminate spinach and other green vegetables in the diet. B. Continue obtaining scheduled laboratory bleeding tests. C. Keep an antidote available in the event of hemorrhage. D. Avoid use of nonsteroidal anti-inflammatory drugs (NSAIDs).

Correct Answer is D

Explanation

Choice A reason: Spinach and other green vegetables are rich in vitamin K, which is essential for blood clotting. However, dabigatran is not affected by vitamin K intake, unlike warfarin, another anticoagulant drug. Therefore, there is no need to eliminate these foods from the diet.

Choice B reason: Dabigatran does not require routine laboratory monitoring of bleeding parameters, such as prothrombin time (PT) or international normalized ratio (INR), unlike warfarin. Therefore, the client does not need to continue obtaining scheduled laboratory bleeding tests.

Choice C reason: Dabigatran is a direct thrombin inhibitor that prevents the formation of fibrin, the main component of blood clots. In case of a major bleeding event, the antidote for dabigatran is idarucizumab, a monoclonal antibody that binds to dabigatran and reverses its effect. However, this antidote is not readily available in most settings and should only be administered by a health care provider. Therefore, the client should not keep an antidote available at home.

Choice D reason: NSAIDs, such as ibuprofen or naproxen, can increase the risk of bleeding by inhibiting platelet aggregation and damaging the gastric mucosa. Therefore, the client should avoid using these drugs while taking dabigatran. The client should consult with the prescriber before taking any other medications, including over-the-counter or herbal products.

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A client reports confusion and blurred vision after receiving a dose of glipizide. Which action should the nurse implement?

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Naxlex Comprehensive Predictor Exams

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